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CONTENTS
1.
Executive summary
2.
Background
3.
Salt or sodium?
4.
Blood pressure
5.
15
6.
21
7.
31
8.
Why 6g?
39
9.
45
10.
Further information
49
11.
References
50
01
EXECUTIVE
SUMMARY
This report summarises the scientific evidence on the links between
salt and health that underpins the 6g a day salt intake target. It draws
heavily on evidence reviewed by the UK Scientific Advisory Committee
on Nutrition (SACN) Salt and Health report (SACN 2003).
02
BACKGROUND
Raised blood pressure (hypertension) is a major risk factor in the
development of cardiovascular disease. In recent decades, a body of
evidence has emerged from scientific research to suggest that a high
dietary salt intake is an important causal factor in the development
of hypertension.
03
SALT OR
SODIUM?
The association between salt and blood pressure relates
specifically to sodium, however the major dietary source
of sodium is sodium chloride i.e. salt.
Overwhelmingly, salt
is the major source
of sodium in the diet.
In addition to salt (sodium chloride) there
is a wide variety of other forms of sodium
in our diet, many of which are used as
additives in food processing, usually to add
flavour, texture or as a preservative (Table 3.1).
Thus total sodium intake is greater than that
estimated from salt alone. However, overwhelmingly, salt is the major source of sodium
in the diet (approximately 90%) and therefore
any recommendation for a reduction in sodium
will, in practical terms, translate into a reduction
in salt. Nonetheless it is important that
reductions in salt intake are not accompanied
by increases in other forms of sodium.
Sodium is an essential nutrient and an
important component of the body water pool.
There are complex physiological processes
which regulate sodium concentration at the
appropriate level, mostly by altering the
amount of sodium excreted by the kidneys.
However, over a prolonged period of time, a
high dietary intake of sodium affects the ability
of the kidneys to respond efficiently. Sodium
excretion is impaired and this leads to an
increase in blood pressure.
Table 3.1
Sources of sodium in foods.
Additive
Sodium citrate
Sodium chloride
Use
Flavouring, preservative
Flavouring, texture,
preservative
Flavour enhancer
Monosodium
glutamate
Sodium cyclamate
Artificial sweetener
Sodium bicarbonate Yeast substitute
Sodium nitrate
Preservative, colour
fixative
Source: Gibney, Vorster and Kok 2002
04
BLOOD
PRESSURE
High blood pressure is one of the most common disorders in the UK
and is an important modifiable risk factor for coronary heart disease
(the leading cause of premature death in the UK) and stroke
(the third leading cause).
Table 4.1
Classification of blood pressure levels.
Category
Optimal blood pressure
Normal blood pressure
High-normal blood pressure
Grade 1 hypertension (mild)
Grade 3 hypertension (severe)
Systolic BP
Diastolic BP
(mmHg)
(mmHg)
<120
<130
130 139
140 159
180
<80
<85
85 89
9099
110
Lifestyle factors
that contribute to
hypertension include
high salt intake, being
overweight, physical
inactivity and excess
alcohol consumption.
Figure 4.1
Stroke mortality rate versus usual systolic
blood pressure at the start of that decade:
a meta-analysis of individual data for one
million adults. (Reprinted with permission
from Lewington et al 2002).
Age at risk:
10
256
80 89
years
128
70 79
years
64
6069
years
32
50 59
years
16
8
4
2
1
120
140
160
180
HYPERTENSION
There are two major clinical classifications of
hypertension. Primary (essential) hypertension
is of unknown cause and is responsible for at
least 90% of all cases. A number of risk
factors, including a high salt diet, increase the
risk of primary hypertension. In secondary
hypertension (approximately 10% of all cases),
a recognised medical condition such as kidney
disease, can be specifically diagnosed.
In England and Wales, the prevalence of
hypertension (classified as blood pressure
of 140/90 mmHg or above or receiving
treatment for high blood pressure) is 32% for
men and 30% for women (Blake et al 2004).
The prevalence of hypertension increases with
age in both sexes (Figure 4.2). In England, the
increase in average systolic pressure between
the ages of 1624 years and 75 years and
above is 18mmHg for men and 30mmHg
for women (Blake et al 2003).
The World Health Organisation (WHO
2002) has estimated that the global burden
attributable to a systolic blood pressure of
115mmHg or above is:
20% of all deaths in men and 24%
of all deaths in women
62% of strokes and 49%
of coronary heart disease
11% of disability adjusted life years (DALYs)
What is a DALY?
Daily Adjusted Life Years are a
measure of the burden of disease
and reflect the total amount
of healthy life lost, to all causes,
whether from premature mortality
or from some degree of disability
during a period of time.
11
12
Figure 4.2
Mean systolic blood pressure by age and sex in England.
(Data from Blake et al 2003).
160
140
120
100
80
60
40
20
Men
Women
0
16 24
2534
35 44
45 54
55 64
65 74
75+
Age (yrs)
Table 4.2
Risk factors for developing hypertension.
13
Hypertension increases the risk of:
05
0
SALT INTAKE
IN GREAT BRITAIN
Salt intake among adults (1664 years) is more than 50% above the
Reference Nutrient Intake (RNI). Only 15% occurs naturally in food and
almost three-quarters of total salt intake comes from processed foods.
15
16
17
Figure 5.1
Salt intake (estimated from 24-hour urinary
sodium excretion) of 1146 adults in Great Britain
(2000-1). (Data from Henderson et al 2003).
Dashed line indicates salt reduction target of 6g per day.
13
12
11
10
9
8
7
6
Men
Women
5
19 24
25 34
35 49
50 64
Age (yrs)
Figure 5.2
Secular trends in salt intake (estimated from
24-hour urinary sodium excretion) of adults
in Great Britain. (Data from Gregory et al 1990
and Henderson et al 2003).
Dashed line indicates salt reduction target of 6g per day.
12
11
10
9
8
7
6
19861987
20002001
5
Men
Women
18
Reasons for using urinary
sodium excretion as a
measure of salt intake
Dietary intake of sodium
is difficult to assess
Most sodium excreted in urine
is derived from dietary salt
Non-urinary losses of sodium
are small
Figure 5.3
Food sources of sodium among adults.
(Data from Henderson et al 2003).
20
35
11
Cereals
Dairy foods
8
26
Meat
Vegetables
Other foods *
eggs and egg dishes, fat spreads, fish and fish dishes,
sugar, preserves and confectionery, drinks and miscellaneous
foods such as powdered drinks, soups and sauces.
19
Figure 5.4
Salt content of commonly consumed foods.
06
0
SALT &
HEALTH
A high salt intake has been associated with an adverse impact on longterm health especially hypertension. This evidence was reviewed in the
SACN Salt and Health report (SACN 2003). Most evidence relates to the
effects of salt on blood pressure and consequently on the risk of vascular
disease. Reductions in salt intake can decrease blood pressure in adults
of different ages and ethnic backgrounds. These improvements can be
enhanced by other concomitant changes in diet and lifestyle.
BLOOD PRESSURE
The scientific evidence relating salt to high
blood pressure is derived from a range of
different types of studies including crosssectional population studies and dietary
intervention studies. It is also supported by
research in animals.Together these studies
suggest that (i) there is an association
between dietary salt intake and blood
pressure, (ii) reductions in dietary intake of
salt can reduce blood pressure, especially in
combination with broader dietary changes.
However the maintenance of a reduced salt
intake over time is poor and the reduction
in blood pressure may not be maintained
with dietary advice alone.
Many studies of the relationship between
diet and health begin with cross-sectional
observations of the differences in dietary
habits between individuals or groups of
people relative to their risk of ill-health.
The evidence for an association between
salt intake (based on 24-hour sodium
excretion) and blood pressure is broadly
consistent across groups of people of
different ages and ethnicity.
Reductions in dietary
intake of salt can reduce
blood pressure, especially
in combination with
broader dietary changes.
21
22
Increases in salt
intake lead to increases
in blood pressure.
However, these ecological data do not address
whether the effect of usual salt intake on
blood pressure is of clinical or public health
relevance. A recent analysis of data from
23,104 people aged 45-79 years, in Norfolk
showed that, within a typical UK population,
there was a significant trend between
estimated salt intake and both systolic and
diastolic blood pressure (Khaw et al 2004).
For people with no history of hypertension,
the risk of having high blood pressure was
more than doubled for the 20% of people
consuming the most salt (top quintile) relative
to the 20% consuming the least salt (bottom
quintile) (Figure 6.1a and 6.1b).
Cross-sectional studies cannot prove that
a high salt intake causes raised blood pressure,
independently of all other factors. Much
stronger evidence can be obtained from
intervention studies where the intake of salt
is changed and the impact on blood pressure
observed over a period of several weeks or
more to allow time for the body to adapt
to the altered intake of salt. Although a large
number of studies have been carried out
which have advised people to decrease salt,
far fewer have rigorously supervised the
dietary change with detailed checks on
compliance and continued to do so over
a long enough period for the body to adapt.
Figure 6.1a
Odds ratio of hypertension (systolic
blood pressure >160mmHg) in relation
to salt intake in men aged 45-79y.
(Data from Khaw et al 2004).
3.5
3
2.5
2
1.5
1
0.5
0
2
3
4
5
Quintile of urinary sodium: creatinine *
Figure 6.1b
Odds ratio of hypertension (systolic
blood pressure >160mmHg) in relation
to salt intake in women aged 45-79y.
(Data from Khaw et al 2004).
3.5
3
2.5
2
1.5
1
0.5
0
2
3
4
5
Quintile of urinary sodium: creatinine *
* Urinary
23
24
Figure 6.2
Change in systolic blood pressure in response to varying
intakes of dietary salt. (Adapted from Sacks et al 2001).
134
132
130
128
126
Control
124
DASH diet
122
120
118
High 9g/d
Intermediate 6g/d
Low 3g/d
Salt intake
Figure 6.3
The relationship between the net change in urinary
sodium excretion and systolic blood pressure.
(Adapted with permission from He and MacGregor 2004).
The slope is weighted by an inverse of the variance of the net change
in systolic blood pressure.
4
2
0
-2
-4
Normontensive
-6
-8
Hypertensive
-10
-12
0
-30
-50
-70
-90
-110
-130
25
26
CORONARY AND
CEREBROVASCULAR DISEASE
High blood pressure is an established risk
factor for vascular disease. Decreases in blood
pressure would therefore be expected to
translate into reductions in coronary heart
disease and strokes.There are, however,
very few studies in which a direct association
has been demonstrated between salt intake
and these diseases.
Cross-sectional associations between salt
intake and death from stroke have been
shown in two large studies. Analysis of data
from the Intersalt study showed a significant
positive relationship between salt intake
(measured by urinary sodium) and death from
stroke (Perry and Beavers 1992). In the
CARDIAC study (WHO Cardiovascular
Disease and Alimentary Comparison) there
was a positive association between urinary
sodium excretion (measured in a sub-sample
of 200 adults) and death from stroke in men
(Yamori et al 1994).
27
28
OTHER POSSIBLE
HEALTH EFFECTS
SUMMARY OF
THE EVIDENCE
29
Lifestyle Intervention
Average reduction
in systolic and
diastolic blood
pressure
5 6mmHg
23mmHg
4 5mmHg
3 4mmHg
3 4mmHg
2 3mmHg
% who achieve a
reduction in systolic
blood pressure of
10mmHg or more
40%
30%
25%
33%
30%
25%
07
31
32
Age
03 months
4 6 months
79 months
1012 months
13 years
4 6 years
710 years
1114 years
Source: Department of Health 1991
33
Age
Up to 6
712
13
4 6
710
1118
months
months
years
years
years
years
Target Average
Salt Intake g/d
Target Average
Sodium Intake g/d
Less than 1g
1g
2g
3g
5g
6g
Figure 7.1
Salt intake (obtained from weighed food records) in young people.
(1.54.5 year olds 19921993), (418 year olds 1997).
(Data from Gregory et al 1995 and 2000).
Dashed lines indicate salt reduction targets
9
8
7
6
5
4
3
2
1.52.5
2.53.5
3.5 4.5
4 6
Age (yrs)
710
1114
15 18
34
Figure 7.2
Sodium intake (obtained from weighed food records)
in young people. (Data from Gregory et al 2000).
45
40
% of participants
35
30
46y
(n=356)
25
20
15
10
5
0
50
100 150 200 250 300 350 400 450 500 550 600 650
Sodium intake (%RNI)
45
40
% of participants
35
30
25
1114y
(n=475)
20
15
10
5
0
50
100 150 200 250 300 350 400 450 500 550 600 650
Sodium intake (%RNI)
35
45
40
% of participants
35
30
710y
(n=481)
25
20
15
10
5
0
50
100 150 200 250 300 350 400 450 500 550 600 650
Sodium intake (%RNI)
45
40
% of participants
35
30
25
1518y
(n=387)
20
15
10
5
0
50
100 150 200 250 300 350 400 450 500 550 600 650
Sodium intake (%RNI)
36
14
16
40
17
40
15
20
21
710 yrs
46 yrs
17
16
38
39
14
15
Cereals
Dairy foods
Meat
23
24
Vegetables
Other foods *
1114 yrs
1518 yrs
* Includes
37
0.2
0.4
0.6
0.8
1.2
08
WHY 6g?
Six grams per day of salt has been set as the national salt intake
target, as part of the broader changes in diet and lifestyle to reduce
the risk of cardiovascular disease.
39
40
41
% of participants
12
10
8
Men
Mean = 11.0g/d
4
2
12
16
20
24
28
32
36
% of participants
12
10
8
Women
Mean = 7.8g/d
4
2
12
16
20
Salt intake (g/d)
24
28
32
36
42
Lifestyle measures
to reduce hypertension
Maintain normal weight for adults
(body mass index 2025kg/m2)
Reduce sodium intake to <100
mmol/day (<6g salt or <2.4g
sodium/day)
Limit alcohol consumption to
3 units/day for men and
2 units/day for women
Engage in regular aerobic physical
exercise (brisk walking rather than
weight lifting) for 30 minutes per
day, ideally on most of days of the
week but at least on three days of
the week
Consume at least five portions/day
of fruit and vegetables
Reduce the intake of total
and saturated fat
Source: Williams et al 2004
43
09
FREQUENTLY ASKED
QUESTIONS
Q1. What are the major
sources of salt in our diet?
A. The majority of salt in our diet comes from
processed foods (6075%). Natural dietary
sources provide about 15%. Salt added at the
table or during cooking provides approximately
10%. About 1% is found in tap water. Cereal
products, including breakfast cereals, bread,
cakes and biscuits provide about one third of
the salt in our diet. Meat and meat products
such as ham provide just over a quarter of
salt in food.
Q2. Why is salt/sodium
added to processed foods?
A. Sodium is added to foods either as salt
or as a number of other additives. Salt gives
food flavour, improves texture (e.g. binding
processed meats), improves colour, and helps
to preserve it and increases the products
shelf life. In some foods, the addition of salt
is inherent to the manufacturing process. For
example in cheese where salt regulates the
activity of starter cultures and controls the
enzyme activity during the maturation process
to help suppress the growth of unwanted
gas-producing bacteria, thus giving cheese
its ultimate flavour and texture.
The Government is currently working with
manufacturers to ensure that, where possible,
salt levels are gradually lowered in processed
foods, making it easier for consumers to
select a low salt diet.
A little is:
0.25g salt
0.1g sodium
45
46
The recommended targets for salt & sodium are given below.
Age
Up to 6 months
712 months
13 years
4 6 years
710 years
11 18 years
Adults
Target Average
Salt Intake g/d
Less than 1g a day salt
1g a day salt
2g a day salt
3g a day salt
5g a day salt
6g a day salt
6g a day salt
Target Average
Sodium Intake g/d
Less than 0.4g sodium
0.4g sodium
0.8g sodium
1.2g sodium
2.0g sodium
2.5g sodium
2.5g sodium
47
10
FURTHER
INFORMATION
Salt & Health: Scientific Advisory
Committee on Nutrition (2003)
A detailed review of the science behind the
current government recommendations for
salt reduction. Includes an executive summary.
Available free online from the Food Standards
Agency website www.food.gov.uk or
purchased from The Stationery Office.
Online information
Visit www.salt.gov.uk for the Food
Standards Agency website packed with
ideas, tips and information about salt.
Consensus Action on Salt and Health (CASH)
www.hyp.ac.uk/cash/ information and scientific
papers on salt reduction.
Salt: facts for a healthy heart
Free information guide produced by the
British Heart Foundation giving practical
advice about lowering sodium intakes.
Copies can be downloaded online at
www.bhf.org.uk or ordered by calling
020 7486 5820.
Salt and your health
Consumer information leaflet produced
by the Food and Drink Federation
www.foodfitness.org.uk. Includes information
on salt targets, reading labels and how
to reduce the salt in your diet.
49
REFERENCES
50
51
52
ACKNOWLEDGEMENTS
With thanks to
Dr Gail Goldberg,
Dr Ann Prentice,
Mamta Singh,
Nilani Sritharan,
Dr Alison Stephen,
Dr Alison Tedstone
and Chris Thane.
Reviewed by
Prof Peter Aggett
Paul Lincoln